Bangladesh Journal of Medicine (BJM)
ISSN : 1023 - 1986
eISSN : 2408 - 8366
ORIGINAL ARTICLE
ACUTE KIDNEY INJURY IN CRUSH SYNDROME AND
RENAL DISASTER-EXPERIENCE IN BANGLADESH
AFTER GARMENT FACTORY COLLAPSE
RATAN DAS GUPTA1, NAZRUL ISLAM2, DILIP KUMAR DEBNATH3, SYED MAHBUB MORSHED4, AMINUR RAHMAN5
Abstract:
Background: Crush-syndrome usually resulting from earthquake and other natural disaster causes
mortality and morbidity. A multistoried garment factory collapsed in Savar, Dhaka, Bangladesh on
24th April 2013 with about 4000 workers. Among the rescued victims, many of them develop crush –
syndrome and AKI that led to a man-made renal disaster in Bangladesh. We analyzed outcome of
severe AKI patient who required renal replacement therapy. Methods: Victims from accident site
were first treated in primarily local hospital and primary care center. Suspected crush syndrome
patients were rapidly transferred to tertiary hospital for dialysis and ICU support. We collect data of
severe AKI patient by a standard questionnairebased onrenal disaster relief force – crush syndrome
patient questionnaire. Results: We had experienced many AKI and crush syndrome after collapsed
garment factory with 3500 workers which created a manmade renal disaster. We observed 27 severe
AKI due to crush syndrome of Rana plaza with mean age 25.12 years, most of them were female
(51.85%). Victims rescued as early as possible, average rescue time was 20.30 hours, 62.96%
developed compartment syndrome and required fasciotomy. All of them got dialysis treatment; some
of them required ICU support. Among all, 67% recovered completely and 26% died. Main causes of
death were infection and DIC with MOF. Conclusions: Crush injury victims who developed severe
AKI, required dialysis. Severe AKI patients who required dialysis had high mortality and morbidity.
Early intervention to prevent AKI and complications may reduce mortality and morbidity.
Key words: AKI, Crush Injury, Renal Disaster
Received: 5.4.2021 Accepted: 28.5.2021
DOI: https://doi.org/10.3329/bjm.v32i2.53797
Citation: Gupta RD, Islam N, Debnath DK, Morshed SM, Rahman A. Acute Kidney Injury in Crush
Syndrome and Renal Disaster-Experience in Bangladesh after garment factory collapse. Bangladesh
J Medicine 2021; 32: 107-112.
Introduction: injury, hyperkalemia, acidosis, cardiac failure,
Crush syndrome refer to systemic manifestations of respiratory failure and infection.4
muscle crush injury by direct trauma or ischemic
Crush syndrome is second cause of mortality and
reperfusion injujry1. Crush injury means compression
morbidity after direct traumatic death.Disintegration
injury between opposing elements leading tissue
of skeletal muscle after prolonged pressure on the limbs
damage. Compression injuries associated with renal
due to stretch insult, ischemicinsult, and ischemic
failure was first described in 1909 after Messenia reperfusion injury lead to rhabdomyolysis5. Increased
earthquake 2 and association between renal failure and permeability of sarcolemma occurs in compressed
crush injury completely describe in 1941 Bywaters and muscles, so calcium, sodium and water move to
Beall3. Crush syndrome refers to muscle injury with intercellular milieu while potassium and myoglobin
systemic manifestations that include tense, edematous efflux to extracellular environment6. After collapse of
and muscle pain, hypovolemic shock, acute kidney building, 80% of the entrapped victims instantly died
1. Associate Professor, Department of Nephrology, Shaheed Suhrawardy Medical College, Dhaka-1207, Bangladesh
2. Professor and Head, Department of Nephrology, Dhaka Medical College, Dhaka-1207, Bangladesh
3. Associate Professor, Department of Nephrology, National Institute of Kidney Diseases & Urology (NIKDU),
Sher-e Bangla Nagar, Dhaka-1207, Bangladesh
4. Assistant Professor ,Department of Nephrology, Shaheed Suhrawardy Medical College, Dhaka-1207, Bangladesh
5. Assistant Professor, Dept of Neurology, Sir Salimullah Medical College, Dhaka-1100, Bangladesh.
Correspondence: Ratan Das Gupta, Associate Professor, Department of Nephrology, Shaheed Suhrawardy Medical
College, Dhaka-1207, Bangladesh, email: [email protected]
Acute Kidney Injury in Crush Syndrome and Renal Disaster-Experience in Bangladesh BJM Vol. 32 No. 2
by the direct trauma, 10% survived with minor injuries ATN and multi -organ failure. Localizes features
and 10% injured badly.Seven out of tenseverely injured includes pain, pressure, pulselessness, paresthesia,
develop crush syndrome and acute renal failure.7 paresis or paralysis and pallor. Systemic features
include hypovolemic shock, hyperkalemia, heart
AKI after rhabdomyolysisdue to (1).Third space fluid
failure, respiratory failure, infection and AKI. Urine
loss in necrosed muscle leading intravascular volume
become dirty brownish discoloration due to
depletion, renal hypo-perfusion and ischemia.(2).
myoglobinuria, biochemical features includeincreased
Myoglobincauses intra-tubular cast formation and
muscle enzymes, urea, creatinine, phosphate,
obstruction, (3). Myoglobin scavenges nitric oxide that
potassium and acidosis.9
aggravates renal hypo perfusioninjury (4). Endotoxin
and cytokines from injured muscle leads renal Initial treatment of crush syndrome includes volume
vasoconstriction.(5). Hyper-uricemia may contribute resuscitation, correction of hypovolemic shock and
cast formation and tubular obstruction, (6). Free iron dehydration and prevention of AKI, lactic acidosis and
from myoglobin which catalyzes. free radical formation, hyperkalemia. Isotonic saline administration 1L/hour
enhance ischemic injury to renal tubules(7). stat initially and monitor volume status, urine output
Hyperkalemia, hyperphosphatemia and hypocalcaemia for further fluid requirement. Victim may needupto 6L
may depress cardiac output and potentiate renal hypo- fluid.
perfusion (8). Inflammation of kidney tissue by
Systemic alkalization by administration of sodium
precipitation of CaPO4 salts. (9). Release of tissue
bicarbonate required to reduce acidosis and
thromboplastin from damage tissue tigers DIC and
hyperkalemia. Sometimes mannitol may require forcing
acute kidney injury8
diuresis. Dialysisand, ICU support may berequired in
Rhabdomyolysis may present with asymptomatic critically ill patients.10
elevation of creatinine kinase or AKI due to oliguric
Rhabdomyolysis
Endotoxin Myoglobinemia
3rd Spacing
Myoglobinuria
Cytokine activation Volume depletion
Renal Hypoperfusion Proximal tubular lesion
Casts
Decrease GFR
Afferent and efferent
arteriolar vasoconstriction
Tubular obstruction
Acute Kidney Injury
Fig.-1 Pathophysiology of Acute Kidney Injury in Rabdomyolysis
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BJM Vol. 32 No. 2 Acute Kidney Injury in Crush Syndrome and Renal Disaster-Experience in Bangladesh
Initial treatment for Crush Syndrome
After extrication
No Fluid before Extrication Received fluid before Extrication.
Initiate Isotonic saline Continue Isotonic Saline
Administer overall 3-6 L Fluid.
Monitor for 6 hours from the initiation of treatment.
Anuria Urine Output +
Intravenous Fluid Close monitoring impossible
(0.5-1L/day + all loses of Close monitoring possible
previous day)
IV fluid (3-6l/day) IV Fluid Morethan 6L/day
Fig.-2 Algorithm for Fluid resuscitation to prevent Crush related AKI
The concept of renal disaster developing after were transferred to Dhaka medical college and National
earthquake in December 1988, Armenia, where 25000 Institute of Kidney Disease and Urology (NIKDU) for
people died, and 600 cases of acute renal failure dialysis, ICU support and specialized treatment. We
developed. Of which 225 victims required dialysis. But observed these severe crush syndrome and AKI
due to no organized support structure with appropriate patients for outcome and complications.
training and deployment strategies response was
ineffective. Poorly organized relief worsens the chaos Methods:
and creates a second disaster, interfering with other All Injured victims initially were admitted in local
global rescue activities. After disappointing experiences hospital. Among the in injured patients, those with
in Armenian earthquake, the international society of severe injury, crush syndrome, compartmental
Nephrology (ISN) install the Renal Disaster Relief Task syndrome or decrease urine volume, were transferred
Force (RDRTF). RDRTF is a logistic organization to Dhaka medical college, NIKDU for specialized
provides organized effort to combat renal disaster and treatment especially dialysis and ICU support. All
save life. ISN-RDRTF effectively participates in selected patients were clinically assessed by pulse,
Marmara, Turkey earthquake in 1999 where 639 blood pressure, urine output, temperature, injury
victims develop AKI related to crush syndrome11. nature and other parameters. All patients investigated
for complete blood count, CPK, Serum creatinine, blood
April24 at 9am 2013, multistoried garment factory urea, serum electrolytes, chest X-ray and other
(Rana Plaza) collapsed in Savar, 50 kilometers from investigations. Crush injury diagnosed based on the
Dhaka, the capital city of Bangladesh, with 3500 presence of swollen limbs and history of limb
unfortunate workers inside. The incident caused more compression12. Crush syndrome includes muscle
than 1139 deaths and 2500injury. Severely crush injury with systemic symptoms of hypovolemic shock,
injured victims developed crush syndrome and acute AKI, hyperkalemia, heart failure, respiratory failure,
kidney injury. 27 crush syndrome and AKI victims and infection13-14. Compartmental syndrome includes
109
Acute Kidney Injury in Crush Syndrome and Renal Disaster-Experience in Bangladesh BJM Vol. 32 No. 2
traumatic injury of limb with pain, pressure, disaster relief force – crush syndrome patient
paresthesia, paresis or paralysis, pallor and pulse- questionnaire.
lessness. Patient with compartmental syndrome
underwent fasciotomy as decided by expert clinician Results:
and surgeon14.AKI diagnosed by decrease urine output After collapse multistoried garment factory,1136 victim
,5ml/kg/hour for 6 hours or increase serum died before extrication, 1762were rescued with different
creatinine>0.3 mg/dl to baseline.15,16Severe AKI types of injury which was minor to severe. 27 severely
includes serum creatinine>4mg/dl, GFR less than 25 injured victims develop crush syndrome and acute
kidney injury, diagnosed by reduce urine output or
mi/min or on RRT or urine volume less than 0.3ml/
rise of serum creatinine, transferred to referral center
kg/hour for 12 hours 15,16Hyperkalemia diagnosed by
for dialysis and ICU support. All victims were young
presence of serum potassium >5.5 mmol/l.All patients
adult working people with mean age was 25.12 (range
with crush syndrome initially treated with adequate
of 14-35) years, male13 (48.15%) and female
fluid replacement and bicarbonate infusion. Oliguric
14(51.85%). Seven victims (25.93%)died during
patients were hydrated with mannitol infusion given treatment. Victims who were extricated for five to
for diuresis. Hyperkalemia treated with insulin forty-sevenhours,(mean 20. 30 hours) after building
&glucose infusion and dialysis. Patient with serum collapse had multiple injury. 62.96% (17) developed
creatinine>6mg/dl, acidosis, persistent hyperkalemia compartment syndrome and required fasciotomy. 24
and volume overload were selected for dialysis through hours Urine output decreased about 0-400 ml (mean
central venous catheter.Outcome of recovery, death, 107.5 ml) and blood pressure reduced systolic 90-
duration of hospital stay and requirement of ICU 150mm of Hg, mean 106.66 mm of Hg and diastolic
support were observed. Partial recovery defined as pressure 40-90 mm of Hg, mean 72.66 mm of Hg. All
serum creatinine remain above normal but not patients required dialysis,average 11 session /patient
dependent on diakysis. Complete recovery defined as (2-24 sessions/pt) and blood transfusion required 2.5
serum creatinine within normal range. Dialysis unit / patient (1-6units/pt). 62.96% of patients
dependent defined aswho require regular dialysis. Data required ICU support with or without ventilator
collected by questionnaireson the basis of renal support. (Table I baseline characteristic of patient)
Table -I
Baseline characteristic
N Range mean Percentage( %)
Male 13 48.15
Female 14 51.85
Age (years) 14-35 25.12
Extrication time (hours) 5-47 hours 20.30 hours
Compartment syndrome 17 62.96
Number of injury 1-5 2.53
Urine output ml /24 hours 0-400 111.48
Fasciotomy 17 62.96
Blood transfusion 1-6 unit 2.59 unit
Dialysis session 2-24 11.66
ICU and ventilation 17 62.96
Ventilation 15 55.56
Blood pressureMm of Hg Systolic 90-150 110.61
Diastolic 40-90 75.35
Death 7 25.93
110
BJM Vol. 32 No. 2 Acute Kidney Injury in Crush Syndrome and Renal Disaster-Experience in Bangladesh
Table-II 28.6 %( 2) develop multiorgan failure and died, 14.2
Biochemical profile % (1) develop ARDS and 14.2% (1) died due to
hyperkalemia before starting dialysis (Fig.-2). In most
Value Mean Range of cases, cause of death was septicemia and multi organ
Haemoglobingm/dl 8.6 6.4-12.5 failure. One patient died before stating dialysis due to
Serum creatinine mg/dl 7.25 4.6-9.2 severe hyperkalemia and one patient died due to ARDS.
Blood urea mg/dl 146 84-280
CPK unit/L 41124.3 3054-125754 Discussion:
Serum potassium mmol/L 5.7 4.2 -8.3 Crush-syndrome and Acute Kidney Injury cases are
seen in after earthquake and others natural calamities,
In Table-II serum creatinine is high 7.25 mg/dl, CPK is also seen in war. We had experienced many AKI and
41124.3 unit/L and serum potassium is 5.7 mmol/L. crush syndrome after collapsed garment factory with
3500 workers which created a manmade renal disaster.
We observed 27 severe AKI due to crush syndrome of
Rana plaza with mean age 25.12 years, most of them
death were female (51.85%) (Table I). Victims rescued as early
26% as possible, average rescue time was 20.30 hours,
62.96% developed compartment syndrome and
required fasciotomy. All of them got dialysis treatment;
some of them required ICU support. Among all 67%
paral recovery completely recovered and 26% died. Main causes of
7% complete
death were infection and DIC with MOF.
recovery
67% Most of the victim was young adult with mean age 25
years. Female were more victimized than male as most
of the workers in the factory were female. Maximum
injured rescued within 30 hours of incidence and mean
rescue time was 20.30 hours and minimum 5 hours.
complete recovery par!al recovery death Most of earthquake extrication time were similar, in
Fig -1: Outcome of the dialysis patient Marmara earthquake rescue time was 24 hours.17 17
(29) victims developed compartment syndrome and
Outcome of the patient shows in Fig.-1: 67.86 %(19) underwent fasciotomy and 2 patient required
patients had complete renal recovery whose creatinine amputation were similar to earthquake victim.5 CPK
became normal with normal urine output. 7.14 % (2) (creatinine phosphokinase) was elevated in most of the
patients had partial renal recovery with serum cases and highest level was 125754u/l and potassium
creatinine not normal but not dialysis dependent. Total level was also increased in every case Table II. This
26% (7) patients died and 27 became dialysis finding is also similar in crush injury patient in
dependent.42.9% (3) died due to septicemia and DIC, earthquake victims17. 26% of crush injured died and
67% were recovered well. Other study in earthquake
Causes of Death victim showed 13-25% died in renal failure related
complications17.
50 42.9
Causes of death were septicemia and DIC, multiorgan
40
28.6
failure, hyperkalemia and ARDS in our study (Fig. 2).
percentage
30 Septicemia was most common cause of death as
infection prevention was difficult in our setting.Most
20 14.2 14.3
of crush injured in Marmara died due to multiorgan
10 failure and hyperkalemia6,17.
0 Mortality in AKI of crush injury is extremely high. Early
intervention and prevention of infection and multiorgan
failure may improve the outcome.
Conclusions:
cause of death After garment factory collapse a significant part of
Fig-2: Causes of Death victim develop crush syndrome and complications
111
Acute Kidney Injury in Crush Syndrome and Renal Disaster-Experience in Bangladesh BJM Vol. 32 No. 2
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